Rejection Codes
79
Refill Too Soon
Which option code should be entered on a claim to view the drug’s NDC?
1
What action code should be entered for claims that are too early to refill within seven days?
RF
Which items qualify as diabetic testing supplies?
Meters, lancets, and test strips (not insulin pumps)
How do you fix a claim stuck in TRPR status?
Process a transfer batch.
41
Bill Other Processor – Submit to Other Processor
How can you find out who updated a resident’s hierarchy last?
Enter option code 12 next to a claim, then enter 3 next to the current hierarchy. User information will display on the top right.
Who should pullouts be sent to?
Dispensing pharmacy for decentralized.
Senior Living Pharmacy Cycle Team for standard.
Billing Inbox
PA Team (if needed)
What does the shipping/delivery code SFBP indicate?
The meds were sent from a backup pharmacy.
What are two ways to determine if a drug has been sent?
Look for SHIPPED or RECVFAC on the tracking screen of a claim in the med profile or in the Task Notes.
40
Pharmacy not Contracted with Plan on D.O.S.
Which option code should be entered on a claim to view which “copay bucket” the resident’s responsibility amount falls into?
SY
Why would you action-code something to Return to Stock?
Refill is too early to send beyond seven days.
Drugs are billable to hospice when used to treat which symptoms?
Anxiety, nausea, constipation, and pain
What should you do if you receive an error when reversing a claim that says Activity Applied- Reverse Activity?
Enter RP on the line next to the claim, then TR in the pop-up box. You can then reverse normally.
56
Non-Matched Prescriber ID
What are two ways to access Facility Maintenance?
1. Enter pharmacy number, 7, 4, and the facility number or shortcode
2. F4 from any screen, then enter PHFAC on the first line and the facility number or shortcode on the second line
If a facility number is orange on the cycle calendar, what does that indicate?
Cycle is a decentralized pharmacy
What happens when a PRB prescription is changed in the middle of the month?
The claim will reverse and rebill with the dispensed amount, and a new claim will generate.
What information do you need to perform a cash price inquiry?
Facility ID or shortcode, resident name or ID, quantity, and NDC.
E7
Metric Decimal Quantity Errors- Plan requires the quantity dispensed to be in a certain multiple of the package size.
What does RVDN status indicate, and how would you resolve it?
REVERSAL DENIED.
Action code IT and open a ticket. Can also require a call to Insurance for reversal.
Where can you find the list of 'Special Cycle' Priority Communities? (cycles with priority other than FCYC)
Share Drive:
Senior Living Billing >Billing Team>Special Cycles
What should you enter on the line next to a pink PCB claim to view dispenses that fall within the billing cycle for that claim?
PC
When should you involve an account manager in a pharmacy research email?
When they need to complete a necessary action or when the pharmacy has been non-responsive for four days (third attempt).